[When a bubble bursts]

A 47-year-old man with a medical history of nephrolithiasis of the right kidney presented with abdominal pain at the level of the right hip. Ultrasonography showed an anechoic area with irregular contours in the lower pole of the right kidney, where a previous ultrasound scan had signalled the presence of a large cyst. Abdominal computed tomography revealed the presence of a fluid area within the lower pole of the right kidney. Subsequent ultrasonography showed progressive reduction of the anechoic area, which was associated with gradual reduction of the pain. The case was diagnosed as spontaneous rupture of a renal cyst. Renal cyst rupture is an infrequent, usually self-limiting event that may engender diagnostic dilemmas.

Transient left ventricular apical ballooning: A unifying pathophysiologic theory at the edge of Prinzmetal angina

INTRODUCTION

Takotsubo or ampulla transient left ventricular apical ballooning (LVAB) cardiomyopathy has been described as a clinical syndrome characterized by the sudden onset of chest pain, cardiac failure, ischemic changes on electrocardiography, and apical severe myocardial dysfunction in the presence of "normal" coronary arteries on angiography. All features last from a few days to a few weeks.

METHODS AND RESULTS

On the basis of previous knowledge and in light of our recent experience with acetylcholine testing in this condition, the cases of four patients are described and preliminary but sound arguments are given to support the theory that LVAB is caused by severe, sustained spasm of many or all of the coronary vessels. In one of these patients, experimental reproduction of LVAB occurred in the catheterization laboratory during acetylcholine testing (as evidenced by echocardiographic monitoring), while in two other patients, the test provoked similar, extensive angiographic vasospasm and suggestive symptoms. In addition, the similarities and differences that exist between LVAB and Prinzmetal angina are discussed.

CONCLUSION

To evaluate the pathogenesis of LVAB, it is proposed that acetylcholine testing be routinely performed under specific, prospective, investigational protocols at specialized centers.

Ectopic origin of left coronary ostium from left ventricle, with occlusive membrane: a previously unreported anomaly, with an embryologic interpretation

Congenital atresia of the left main coronary artery, a condition in which the left main trunk is developed but has been occluded since birth, is a rare coronary anomaly. Herein, we describe this anomaly's association with a subannular location of an obliterated left main ostium in a patient with a bicuspid aortic valve and severe aortic stenosis. The patient underwent successful surgery. We discuss the embryologic implications of congenital atresia of the left main coronary artery, in view of the exceptional anatomic features of this condition. To our knowledge, this is the 1st report of a left coronary artery that was found to arise from the left ventricle.

Split right coronary artery: its definition and its territory

We report here, for perhaps the 1st time in the English-language literature, the extent of the territory fed by the anterior bifurcation of the (anomalous) split right coronary artery (RCA). A 64-year-old man presented with an occlusion of the anterior bifurcation of a split RCA--which resulted in an infarct that involved both the inferoseptal left ventricular wall and the anterior right ventricular free wall. Split RCA is the same anomaly as the improperly named "double right coronary artery." In reality, there are not 2 RCAs, but only split portions of the posterior descending branch of the RCA, with 2 separate proximal courses.

"Acute takeoff" of the circumflex artery: a newly recognized coronary anatomic variant with potential clinical consequences

Human coronary anatomy allows for a wide range of anatomic variants while maintaining certain consistent features. The use of specific descriptions and names is helpful in talking about variants that have an implicit potential for clinical consequences. In reviewing the angiograms of 813 patients, we newly identified a coronary pattern that we propose to name "acute takeoff of the circumflex artery" in 16 patients (2%). This previously unreported pattern angiographically features a <or=45 degrees angle between the mainstem of the left main stem and the circumflex coronary artery in 2 orthogonal, caudal projections. The acute angle is associated with a substantially longer left main trunk than that seen in the general population (24.9 vs 9.8 mm, respectively). This anomaly increases the technical difficulty and failure rate of percutaneous coronary intervention unless the operator makes specific adaptations, some of which we describe herein.

Retractable-needle catheters: an update on local drug delivery in coronary interventions

In the treatment of coronary artery disease, local delivery of pharmaceutical substances has long been a goal, yet the technology is still evolving. Coronary stents have become the predominant means of treating obstructive lesions, and the need for additional pharmacologic treatment is evidenced by the popularity of drug-eluting stents. Moreover, stents have residual limitations, in particular in-stent thrombosis and late restenosis. Investigators have recently proposed delivering coronary drugs by means of local injection devices. These innovative devices, which incorporate retractable needles at the tip of a catheter, appear to be ready for clinical testing. In addition to solving many of the limitations of drug-eluting stents, local injection devices may eventually enable interventional cardiologists to treat vulnerable plaques. Herein, we review the evolution and current status of local drug delivery in the coronary arteries, with an emphasis on novel catheters that have retractable needles.

Infection with chikungunya virus in Italy: an outbreak in a temperate region

BACKGROUND

Chikungunya virus (CHIKV), which is transmitted by Aedes spp mosquitoes, has recently caused several outbreaks on islands in the Indian Ocean and on the Indian subcontinent. We report on an outbreak in Italy.

METHODS

After reports of a large number of cases of febrile illness of unknown origin in two contiguous villages in northeastern Italy, an outbreak investigation was done to identify the primary source of infection and modes of transmission. An active surveillance system was also implemented. The clinical case definition was presentation with fever and joint pain. Blood samples were gathered and analysed by PCR and serological assays to identify the causal agent. Locally captured mosquitoes were also tested by PCR. Phylogenetic analysis of the CHIKV E1 region was done.

FINDINGS

Analysis of samples from human beings and from mosquitoes showed that the outbreak was caused by CHIKV. We identified 205 cases of infection with CHIKV between July 4 and Sept 27, 2007. The presumed index case was a man from India who developed symptoms while visiting relatives in one of the villages. Phylogenetic analysis showed a high similarity between the strains found in Italy and those identified during an earlier outbreak on islands in the Indian Ocean. The disease was fairly mild in nearly all cases, with only one reported death.

INTERPRETATION

This outbreak of CHIKV disease in a non-tropical area was to some extent unexpected and emphasises the need for preparedness and response to emerging infectious threats in the era of globalisation.

Newer concepts for imaging anomalous aortic origin of the coronary arteries in adults

Of the different kinds of coronary anomalies observed in adults, anomalous origin of a coronary artery from the opposite sinus of Valsalva with an "interarterial" course (ACAOS) entails a high risk of clinical consequences related to the intramural course of the ectopic coronary artery. We review current imaging modalities for differentiating this condition from generally benign coronary anomalies and for quantifying the severity of individual cases. For identifying ACAOS, noninvasive modalities (echocardiography, computed tomographic angiography, and coronary magnetic resonance angiography) are preferred: the favored modalities are transthoracic echocardiography in children and multidetector computed tomography in adults. For evaluating the pathophysiologic mechanisms of ischemia in ACAOS and subclassifying the severity of individual forms, coronary intravascular ultrasonography provides enhanced temporal and spatial resolution. The critical quantifiable features of the coronary anatomy in ACAOS seem to be hypoplasia, lateral compression at the level of the intramural course, and possibly exercise-related further narrowing of the proximal ectopic segment. Definitive guidelines are being developed for the optimal workup and treatment of ACAOS.

Coronary artery anomalies: an entity in search of an identity

Coronary artery anomalies (CAAs) are a diverse group of congenital disorders whose manifestations and pathophysiological mechanisms are highly variable. The subject of CAAs is undergoing profound evolutionary changes related to the definition, morphogenesis, clinical presentation, diagnostic workup, prognosis, and treatment of these anomalies. To understand the clinical impact of CAAs, the fundamental challenge is the firm establishment, for a particular type of CAA, of a mechanism capable of interference with the coronary artery's function, which is to provide adequate blood flow to the dependent myocardium. The present review focuses on anomalous origination of a coronary artery from the opposite sinus--the subgroup of CAAs that has the most potential for clinical repercussions, specifically sudden death in the young. For this subgroup, solid diagnostic screening protocols should be established, especially for athletes and other young individuals subjected to extreme exertion. Intravascular ultrasonography is the preferred means to evaluate the mechanisms responsible for ischemia in anomalous origination of a coronary artery from the opposite sinus and other potentially significant CAAs. Patients symptomatic of anomalous origination of a coronary artery from the opposite sinus may undergo medical treatment/observation, coronary angioplasty with stent deployment, or surgical repair. To be competent to advise CAA carriers, especially in the context of sporting or military activities, cardiologists should undergo specific training in these disorders. Only multicenter collaboration on protocols dedicated to CAAs can give rise to the large-scale studies needed to define the prognosis and optimal treatment of these disorders.

Successful ablation of atrioventricular node reentry tachycardia in a patient with crisscross heart and situs inversus levocardia

Crisscross heart is a complex congenital anomaly that is rarely seen in the absence of important associated structural defects. We describe a 41-year-old woman with recurrent dizziness and tachycardia but no previous cardiovascular symptoms. Narrow-QRS tachycardia was detected, and magnetic resonance imaging showed situs inversus levocardia with a circulatory pattern typical of crisscross heart. Electrophysiologic study revealed atypical atrioventricular (AV) node reentry tachycardia of the "fast-slow" type. Despite the unusual anatomy, we successfully modified the AV node physiology by ablating the "slow AV node inputs" with the guidance of a multielectrode basket catheter in the anatomic right atrium.

The "1st septal unit" in hypertrophic obstructive cardiomyopathy: a newly recognized anatomo-functional entity, identified during recent alcohol septal ablation experience

In hypertrophic obstructive cardiomyopathy, selective and asymmetric hypertrophy results in a stenotic subaortic channel, which is further narrowed by a Venturi effect (suctioning of the anterior leaflet, manifested by systolic anterior motion of the mitral valve). Better understanding of these essential pathophysiologic mechanisms has led to the definition of a new anatomo-functional entity, the 1st septal unit, which consists of the basal interventricular septal hypertrophy and its related septal arterial branches. As an alternative to surgical myomectomy, alcohol septal ablation is an effective method of reducing subaortic stenosis and improving mitral valve function. After alcohol ablation, global negative remodeling of the hypertrophied left ventricle eventually ensues. This review presents specific anatomic and functional features of a newly identified pathophysiologic entity (the 1st septal unit) in relation to the clinical manifestations and natural history of hypertrophic obstructive cardiomyopathy. This relationship is also relevant during the performance of alcohol septal ablation interventions: related operative suggestions are provided for optimizing subaortic stenosis relief during septal ablation and for preventing complications.

Single coronary artery with prepulmonic coursing left main coronary artery manifesting as prinzmetal's angina

We report the case of a 32-year-old man who presented at the emergency department with severe chest pressure, left arm pain, and dizziness. These symptoms were described as intermittent, occurring after exercise and at rest. He had undergone several stress tests during the past 8 years, but no objective evidence of ischemia was produced. His history of hyperlipidemia and increasing frequency of symptoms prompted us to perform coronary angiography, which showed a single coronary artery with an ostium at the right sinus of Valsalva. The vessel had an initial, mixed common trunk that gave rise to both the right coronary artery proper and to the left coronary artery. The left main trunk followed a prepulmonic course. The anatomic features were eventually confirmed by computed tomographic angiography. The left main stem had a fixed 50% to 60% area narrowing, at baseline study. A treadmill stress myocardial perfusion study showed no evidence of ischemia. The patient was referred to a 2nd facility, where intravascular ultrasonography, at baseline, revealed 63% left main narrowing without evidence of atherosclerosis. Acetylcholine provocation demonstrated worsening of the stenosis to about 80%, with reproduction of angina and ST-segment depression, which indicated that medical management of spasm might provide symptomatic relief.

High dose pulsatile dexamethasone therapy in children with opsoclonus-myoclonus syndrome

Opsoclonus-myoclonus syndrome (OMS) is a rare movement disorder characterized by chaotic eye movements, myoclonus, and ataxia associated with severe irritability. Different treatment modalities including steroids and cyclophosphamide have been tried in the past often with significant side effects and variable success. Here we present 11 children, diagnosed with OMS between 1999 and 2005 and treated with high dose dexamethasone pulses. Main symptoms at presentation were opsoclonus (11/11), ataxia and/or myoclonus (11/11), irritability (10/11) associated with a neuroblastoma in four children. Number of dexamethasone pulses ranged from 6 to 60 pulses. No major side effects were reported. In 6/11 children a complete and sustained remission of OMS symptoms was achieved after 6 to 29 pulses of dexamethasone. Two children from this group have a normal development and no neurological sequelae. Two further children have minor delays in fine- and gross-motor skills. Two children despite a complete recovery of OMS symptoms have persisting developmental problems. 5/11 children still require regular dexamethasone pulses in addition to daily prednisolone (n = 1) or have received cyclophosphamide pulses meanwhile (n = 2). All children continue to have developmental and neurological difficulties. In summary treatment with high dose pulsatile dexamethasone appears to be safe and beneficial in a subgroup of patients with OMS.

[Ultrasound investigation in Apulo-Lucano renal echography study group of the Italian Society of Nephrology: a cognitive report]

The number of ultrasonography expert consultant Nephrologists is more and more increasing thanks to the contribution that this methodology has brought in both clinical and treatment fields. Up to now, a database of the ultrasonography benefits, as well as the main criteria for the interpretation of the urinary tract echographic examination has not been compiled, yet. We have therefore drawn up and distributed a questionnaire to the consultant nephrologists of the urinary tract echography study group (Apulo-Lucano division). This questionnaire is made up of 27 ultrasonography application and interpretation issues; it aims mainly at creating a common 'language' to reduce the variety of 'descriptors' currently employed by all different specialists and centres involved. 60 consultant nephrologists participated in the study, from the 29 Nephrology and Dialysis O.U.s of Puglia and Basilicata regions, where there is an active echographic service. Data collected show the key role of ultrasonography investigation for all nephrology patients, as high quality and cost efficient test procedure. Moreover, despite the fact that there are differences in echographic examination performance and interpretation, literature data show clearly that it is fundamental to follow general shared principles. The responsibility and task of those specializing in this discipline should be to allow reproduction and comparison of ultrasonographies, also among different operators and centres, and meta studies, i.e. 'a series of comparative studies', which are still very few in number.

[A girl in the mirror]

We report a case of situs ambiguous associated with particular vascular anomalies resulting in secondary arterial hypertension. Renal ultrasonography performed in this case has oriented diagnosis.

Hospitalization rate due to measles in an area of the South East of Italy during an outbreak in the years 2002-2003

AIM

Usually measles is not severe, but serious complications can occur and thus hospitalization is needed. The aim of this study was to assess the reasons of hospitalizations of the persons affected by measles and the severity of disease as a result of measles infection.

METHODS

During an outbreak from 2002 to 2003 in the province of Taranto, 73 hospitalized persons affected by measles were evaluated.

RESULTS

The age of the 73 hospitalized patients ranged between 1 and 42 years old (median age 14.5 years). An hospitalizations rate of 63% was reported in the first 4 months of 2003. Measles-related complications were observed in 35.6% of cases. In 14 cases (19%) we observed a pneumonia with a concomitant myocardititis and pancreatitis in 2 cases. Postmeasles encephalitis was diagnosed in 7 cases (9.5%). In 2 cases a concomitant myelitis occurred, with the presence of sequelae at the time of discharge but none permanent. Measles related appendicitis was observed in 5 males (6.8%) and appendectomy was performed in all cases. Data analysis showed that the patients with an age <15 years old had a higher risk of complications than patients with an age > or =15 years. None death was reported.

CONCLUSIONS

At present, measles and its related complications continue to be a serious illness even in industrialized countries, only a complete immunization vaccine strategy could permit measles' eradication.